I, the undersigned, hereby authorize Green Creek Education (the “School”), and its designated agents or contracted screening providers, to conduct a background screening for the purpose of determining my eligibility for enrollment and/or participation in required clinical training, in accordance with Missouri law, applicable regulatory requirements, and clinical site policies.

I understand and agree that, when required by program or clinical placement requirements, the background screening may include the collection and review of criminal history records, sex offender registry checks, and other applicable public record information from local, state, and/or federal sources. Such screening may include fingerprint-based criminal history record checks conducted through the Missouri State Highway Patrol (MSHP) and/or the Federal Bureau of Investigation (FBI), if applicable.

I understand that the information obtained through this background screening will be used solely for educational, enrollment, and clinical eligibility purposes, and not for employment, and will be handled in accordance with applicable federal and Missouri laws, including the Fair Credit Reporting Act (FCRA) and relevant Missouri statutes. Green Creek Education will not unlawfully discriminate or misuse background screening information.

I authorize the release of background screening information to Green Creek Education, its designated representatives, and contracted screening providers on a need-to-know basis only, for the purposes described above.

I hereby release and hold harmless Green Creek Education, and any law enforcement agency, screening provider, or individual providing such information, from liability arising from the lawful release and use of background screening information in accordance with this authorization.

Background screening for applicable programs may be conducted through the Missouri Family Care Safety Registry (FCSR) and/or other state-approved or clinical site–required screening methods

Green Creek Education occasionally photographs, records, or captures images, audio, or video of students for educational, instructional, and informational purposes.

Participation in media activities is completely voluntary. Declining or revoking consent will not affect enrollment, grades, clinical placement, program completion, or standing with the school.

Purpose of Media Use

If consent is granted, media may be used for the following purposes:

• Educational and instructional materials
• Learning management system (LMS) content
• School publications, presentations, or training materials
• School website and social media platforms
• Marketing or informational materials related to Green Creek Education programs

Media will not be used in a misleading, defamatory, or inappropriate manner.

Consent Selection (Required)

Please select one option below:

Consent and Authorization

By signing below, I voluntarily grant permission to Green Creek Education to photograph, video record, audio record, or otherwise capture my likeness, voice, or participation during school-related activities, classes, simulations, or events, when permitted by applicable clinical site policies.

I understand that:

• Granting consent is optional
• Media may be used without compensation
• Media may be edited for clarity or length but not for misrepresentation
• My name will not be used unless I provide separate written permission

Limitations and Protections

• Green Creek Education will not sell my image, likeness, or recordings.
• Media will be used only for legitimate educational or school-related purposes.
• This consent does not authorize use of protected health information (PHI).
• Clinical sites may have additional restrictions, and media capture may not occur in certain settings.

Right to Decline or Revoke

I understand that I may:

• Decline consent by not signing this form, or
• Revoke consent at any time by submitting a written request to Green Creek Education

Revocation will apply to future use only and will not affect media already produced or distributed prior to the revocation.

Please note the following information is for educational purposes only and does not constitute legal advice.

For the purposes of this consent and release, the term “student” refers to an individual enrolled in a Green Creek Education program that includes a clinical training component.

Certain clinical training sites require drug and/or alcohol screening as a condition of participation. If required by a clinical site or program requirement, I understand that I may be required to submit to a urine drug screen (urinalysis) and/or a breath alcohol test. The purpose of this screening is to determine the presence of controlled substances and/or alcohol in my system in accordance with clinical site policies.

I understand that drug and/or alcohol screening is not required for program enrollment but may be required prior to or during clinical participation. I further understand that a confirmed positive result, refusal to test, or failure to comply with required screening procedures may result in my inability to participate in clinical training, which may impact my ability to successfully complete the program.

I authorize Green Creek Education and its authorized agents to release the results of any required drug and/or alcohol screening, and related documentation, on a need-to-know basis only, to:

• Green Creek Education Administration, and
• The applicable clinical placement site and/or designated screening vendor, including Infection Risk Solutions, LLC (if applicable).

I acknowledge that this consent is voluntary, that I have read and understand the information above, and that a copy of this consent may be maintained electronically and shall have the same force and effect as the original.

I have carefully read the foregoing, and I fully understand its contents. I acknowledge that my signing of this Student Drug and Alcohol Screening Consent is voluntary and that I have not been coerced into signing this document. I understand that this consent relates to clinical participation requirements and not to employment. I further agree that a reproduced or electronically signed copy of this consent shall have the same force and effect as the original.